The Employee Retirement Income Security Act (ERISA) governs approximately 2.5 million health benefit plans sponsored by private sector employers nationwide. These plans provide a wide range of medical, surgical, hospital and other health care benefits to some 131 million Americans.
Under ERISA, workers and their families are entitled to receive a summary plan description (SPD). The SPD is the primary document that gives information about the plan, what benefits are available under the plan, the rights of participant and beneficiaries under the plan, and how the plan works.
Among other information, the SPD of health plans must describe:
Cost-sharing provisions, including premiums, deductibles, coinsurance and copayment amounts for which the participant or beneficiary will be responsible
Annual or lifetime caps or other limits on benefits under the plan
The extent to which preventive services are covered under the plan
Whether, and under what circumstances, existing and new drugs are covered under the plan
Whether, and under what circumstances, coverage is provided for medical tests, devices and procedures
Provisions governing the use of network providers, the composition of provider networks and whether, and under what circumstances, coverage is provided for out-of-network services
Conditions or limits on the selection of primary care providers or providers of specialty medical care
Conditions or limits applicable to obtaining emergency medical care
Provisions requiring preauthorizations or utilization review as a condition to obtaining a benefit or service under the plan
The SPD must also explain how plan benefits may be obtained and the process for appealing denied benefits.
ERISA also requires that SPDs be updated periodically. Furthermore, ERISA requires disclosure of any material reduction in covered services or benefits to participants and beneficiaries generally within 60 days of the adoption of the change through either a revised SPD or a summary of material modification (SMM). Material changes that do not result in a reduction in covered services or benefits must be disclosed through an SMM or revised SPD not later than 210 days after the end of the plan year in which the change was adopted.
The department's claims procedure regulation describes your right to get an answer from your health plan regarding your health benefit claim. The regulation protects you — providing for a timely response by describing the time frames for a decision, providing for a fair process by describing the standards for a decision, and providing for meaningful disclosure by describing the notice and disclosure that you are entitled to receive from your plan. Look to the SPD for information on your health plan's claims procedure.